Accidental addict

Julia Medew

Narelle Caldwell had to wean herself off oxycodone and now uses meditation and exercise to help manage her pain. Photo: Brock Perks

Overprescription of addictive painkillers is creating an epidemic of people with legal drug habits.

WHEN Narelle Caldwell suffered an agonising back injury two years ago, she was grateful to receive one of the strongest painkillers on the market.

At first, the opioid known as oxycodone worked like magic, dissolving the pain from a slipped disc between her shoulder blades almost instantly. But over the course of a few weeks, its power started to wear off. Fearful her pain would return, Caldwell started to watch the clock. She was counting down the minutes until she could take another pill.

''It completely took over my thinking,'' she says. ''I couldn't function without it. I was completely consumed by the fear of the pain and what it was going to do to me.''

The oxycodone gave her a pleasant feeling, too. Not a euphoric high, but a sense of relief and relaxation that made her feel a bit dopey. Caldwell tried to stick to the recommended times to take her pills, but as her tolerance grew, she couldn't resist taking them more often. After two months of chasing her pain with various opioid formulas and other medications to offset their side effects, her boss suggested she do a three-week pain management course.

She agreed and when she got in, a doctor told her she had to come off the drugs so she could find other ways to manage her pain. It was going to be an uncomfortable ride, he said, because whether she liked it or not, she was already dependent and had to withdraw.

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''It was amazing. When I stopped taking them, I went through the whole thing, I had night sweats, I couldn't sleep, I was agitated and fidgety and I was having mood swings,'' Caldwell says. ''It took about two weeks for the drug haze to lift.''

Since the course, Caldwell, 49, has stayed off opioids and now manages her pain with meditation and exercise, among other things. She says her short time on oxycodone introduced her to the intense pull of addiction. She can see how some get lost forever.

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''I'm so glad I got into that program because if I didn't, I would still be taking those drugs and wouldn't have a life,'' she says.

Caldwell, a well-educated woman who has never smoked, let alone taken illicit drugs regularly, is one of a growing number of Australians who have got hooked on opioid painkillers.

Prescription of the drugs, which were once reserved for acute pain such as broken bones or post-surgical wounds, has soared over the past two decades as doctors started thinking they were useful for chronic pain and degenerative conditions like arthritis. But the shift has had unintended consequences. Many patients are being given them for long periods of time, causing them to spiral into addiction or worse - overdose.

Wider availability of the drugs has also created a thriving black market. As drug companies started making them in every conceivable form - pills, patches, syrups, suppositories, nasal sprays, the list goes on - illicit drug users increasingly realised they, too, could use the drugs to get high.

In the US, where opioids have been prescribed most liberally, more people are using the drugs for pleasure now than heroin, cocaine, hallucinogens, ecstasy, and inhalants combined.

Australia is heading in the same direction. The last national drug survey found non-medical use of prescription drugs was 21 times more common than heroin use. While many are happy to pop pills, the injecting drug using community has learnt how to crush tablets and modify skin patches so the drugs can be injected for a more intense high. The trend is so strong that doctors at Sydney's medically supervised injecting centre recently reported that two-thirds of their 225 daily clients were now injecting prescription opiates, especially OxyContin.

Growing demand has meant doctors are being asked for the drugs more often. While many are alert to illegitimate drug seeking behaviour and report it to health authorities (more than 100,000 suspected ''doctor shoppers'' were reported to Medicare last year), some are still being tricked by scams.

Several Australian health departments have warned doctors about new methods in recent years, including fake prescriptions being generated from images on the internet and people successfully posing as doctors to convince others the prescriptions they are asking for are legitimate.

According to the Victorian Department of Health, one person recently used a fraudulent letter from a hospital specialist to obtain 820 OxyContin tablets in two months from 22 doctors. Others have been stealing sheets from prescription pads while their doctors are not looking.

Some doctors now believe elderly people - the group most commonly prescribed opioids - are selling their drugs or passing them on to demanding friends and relatives who are misusing them.

The phenomenon, known as ''fossil pharming'', is worrying Adelaide pain specialist Dr Penny Briscoe, who says all Australian patients on opioids should be routinely drug tested to make sure they are actually taking their drugs.

''People are saying they are getting them out of their grandmothers' cupboards and we've had one palliative care patient admit to selling them to supplement his income - so diversion is occurring, we just don't know how common it is,'' she says.

Briscoe says urine testing would also allow doctors to check that patients are taking their medication safely because people on opioids are at high risk of overdose if they mix them with alcohol or other drugs.

She says in the United States, where monitoring of all patients on opioids is recommended, up to 20 per cent of patients have urine and drug screens that do not match the medication they are reportedly taking.

''If you do the test and you get an unusual result, it gives you the chance to sit down with the patient and say, 'OK, I'm really confused. This isn't showing up as it should so perhaps you and I need to have a chat about this.' Colleagues in Perth have said it's quite useful in that it lets someone say, 'Well, actually I haven't told you something, doc','' she says.

Aside from concerns about diversion, doctors have very good reason to closely monitor their patients' opioid use. Accidental and intentional overdose deaths are mounting, and many are being reviewed by coroners who are asking what went wrong. In most cases, the deceased have mixed their drugs with alcohol or other medications, causing respiratory failure or aspiration - the inhalation of saliva, food or other liquids into their lungs.

Recent research by the National Drug and Alcohol Research Centre at the University of New South Wales found 500 Australians aged 15 to 54 died of an opiate overdose in 2008, up from 360 in 2007. Only one-third of them involved heroin. Preliminary figures suggest there were 612 such deaths in 2009, a 22 per cent increase from 2008, and 705 in 2010, a 15 per cent increase from the year before.

Head of addiction medicine at Melbourne's Western Hospital, Dr Mike McDonough, says while concern about prescription opioids has been growing in Australia for years, there was now a universal feeling among doctors that it was getting out of control.

While some people can function well on opioids for a long time, he says the painkillers are turning some ordinary people with no history of substance abuse into addicts. In some specialist pain clinics, he says these people are sharing tips in waiting rooms about how to crush their tablets and inject them because their doctors are not giving them enough to satisfy their need. ''These are people who would have never imagined themselves injecting drugs.''

McDonough says doctors and governments are now debating ways of limiting supply of the drugs to reduce harm in a way that does not deny doctors reasonable access to them to treat pain. While opioids have their place, he says GPs need to know there is no evidence supporting their long-term use for chronic pain.

However, many GPs are already in a difficult position with patients potentially both addicted and relying on the drugs to manage pain. Long waiting lists of up to a year for specialist pain and addiction medicine mean many GPs are continuing to prescribe opioids to people who need to stop taking them and, if necessary, find alternatives for pain management and relief.

Head of clinical services at Turning Point Alcohol and Drug Centre in Melbourne, Dr Matthew Frei, says this shortage of services is exacerbating the problem because the longer patients stay on the drugs, the more risks there are to their health. Aside from overdose, these risks include hormone disruption, gastrointestinal problems and immunosuppression.

''These people still need care, so GPs can't shut their doors to them but they also need to know when they're doing more harm than good … We need to give GPs the tools to manage these people because the numbers are only going to get more difficult.''

Adelaide-based GP and addiction medicine specialist Dr Philip Crowley says there is also a short supply of GPs willing to provide proven pharmacotherapy treatments for addiction such as methadone and buprenorphine, because the patients who require them are difficult and often need bulk billing.

''As a GP, I can earn more money treating someone for a cold than treating someone for an opiate addiction, so the economics are against it,'' he says. ''These people are complicated patients as well, they take time and they are high risk. If something goes wrong, they can die.''

Furthermore, Crowley says people wanting to use these alternatives to opiates have to pay between $25 and $50 a week for them when they could be spending less money on the drugs they actually want.

''The argument has always been, 'Oh well, it's cheaper than heroin', but these days you can get 20 tablets of morphine for $6 if it's subsidised through the government, so the government is actually subsidising the problem without helping with treatment.''

After years of lobbying, the federal government announced in February that it would spend $5 million on a real-time prescription-monitoring system to help doctors see a patient's prescription history so they can curb ''doctor shopping''.

The national system was to be made available to the states and territories by July this year, but so far only South Australia, Western Australia and the ACT have signed licences to access the web-based network. Last month, the Victorian government said there was ''significant detail to be worked through'' to see if the scheme would work and warned it was no ''magic bullet''. Funding is believed to be the cause of wrangling between the states and the federal government, but none of the governments is willing to say so.

A federal government spokeswoman refused to say when the system would be running nationally, but said it had the backing of all states and territories and would be implemented as soon as possible.

Associate Professor Milton Cohen, a pain specialist at St Vincent's Hospital in Sydney who recently worked on new opioid prescribing guidelines for the Australian and New Zealand College of Anaesthetists Faculty of Pain Medicine, says the delay is frustrating because the growing opioid problem is exacerbating the stigma for people with chronic pain.

He says about one in five Australians has chronic pain - consistent daily pain that lasts for three months or more - and that only about half of them find opioids useful for pain management.

''Having chronic pain is already quite stigmatising. People are called bludgers or accused of putting it on and now, if they're being prescribed these drugs, they are presumed to be addicts,'' he says. ''Opioids are not the be all and end all, but if they're used properly they can improve people's quality of life.

''We're interested in the quality use of opioids, using them for the right person at the right dose and for the right time, so if this is getting out of hand we need to be able to track it.''

Narelle Caldwell backs the call for action. In particular, she says the government should boost specialist pain management services so people can learn to manage pain without drugs sooner rather than later.

''You really have to learn to control the pain yourself without the drugs and through other natural therapies, but that takes a long time. People need strong support from professionals to get to that point.''